What happens to the posterior compartment and bowel symptoms after sacrocolpopexy? Evaluation of 5-year outcomes from E-Care

Abstract

OBJECTIVES

To describe posterior prolapse (pPOP) and obstructed defecation (OD) symptoms 5 years after open abdominal sacrocolpopexy (ASC).

METHODS

We grouped Extended Colpopexy And urinary Reduction Efforts (E-CARE) trial participants with baseline and 5-year outcomes into 3 groups using baseline posterior POP-Q points and concomitant posterior repair (PR): No PR (Ap<0); No PR (Ap≥0); and +PR. Posterior colporrhaphy, perineorrhaphy or sacrocolpoperineopexy were included as PR, which was performed at surgeon’s discretion. Outcomes were dichotomized into presence/absence of pPOP (Ap≥0) and OD symptoms (≥2 on one or more questions about digital assistance, excessive straining, or incomplete evacuation). Composite failure was defined by both pPOP and OD symptoms or pPOP reoperation.

RESULTS

Ninety participants completed baseline and 5 year outcomes or were retreated with mean follow-up of 7.1±1.0 years. Of those with No PR (Ap<0), two women [2/36 (9%)] developed new pPOP with OD symptoms; 1 underwent subsequent PR. Nearly all [23/24 (96%)] with No PR (Ap≥0) demonstrated sustained resolution of pPOP and none underwent PR. Fourteen percent (4/29) of +PR underwent repeat PR within 5 years and 12% had recurrent pPOP. Regardless of PR, OD symptoms improved in all groups after ASC, although OD symptoms were still present in 17-19% at 5 years.

CONCLUSION

Symptomatic pPOP is common 5 years after ASC regardless of concomitant PR. OD symptoms may improve after ASC regardless of PR. Recurrent pPOP and/or reoperation was highest among those who received concomitant PR at ASC. Further studies identifying criteria for concomitant PR at the time of ASC are warranted.

INTRODUCTION

The relationship between defecatory symptoms and pelvic organ prolapse is poorly understood and when to repair a posterior defect during apical prolapse surgery is not well established. Posterior pelvic organ prolapse (pPOP) commonly occurs with other vaginal compartment defects, including apical prolapse; and it may be associated with bulge and/or defecatory dysfunction symptoms. Defecatory dysfunction is a constellation of symptoms that encompasses difficulty with passing stool, excluding anal incontinence.(1, 2) A subset of defecatory dysfunction is obstructed defecation (OD) which can be related to anatomic abnormalities of the posterior compartment including pelvic organ prolapse, perineal descent, intussusception, rectal prolapse, or dysynergic defecation.(3) Complaints of defecatory dysfunction and OD are common among women with pelvic organ prolapse, especially of the posterior compartment. Because chronic straining may occur as result of and may result in pelvic organ prolapse, the causal relationship between prolapse and OD symptoms is not clear. There is a poor correlation between the extent of posterior vaginal prolapse and the presence or severity of OD symptoms.(4-6) However, repair of posterior compartment prolapse is often associated with improvement in defecatory symptoms, although this is less clear in those with predominant apical prolapse. (1, 5, 7, 8)

Consequently, the indications for concomitant posterior repair (PR) during pelvic reconstructive surgery are not evidence-based, and different surgeons have different approaches. While some advocate that restoration of apical support alone may resolve symptomatic posterior defects, others have shown recurrent or new posterior defects regardless of concomitant PR. (9, 10) Similar to reported associations between retropubic urethropexy and subsequent posterior wall defects, it is possible that a good apical repair may provide tension on the apex that then deflects abdominal pressure to the posterior wall (ie above the level of the rectovaginal fascia and below the level of the mesh coverage) resulting in posterior vaginal wall prolapse. (11) However, data regarding increased enterocele formation are likely more related to steep deviation of the anterior wall of the vagina to the pubic symphysis. Symptom correlation with these defects has not been well established. Some surgeons only fix a posterior compartment prolapse when they feel the defect produces symptoms or when significant prolapse is present even in the absence of symptoms.(12) At this time, there is no commonly agreed upon threshold for symptoms or prolapse severity for which intervention for the posterior compartment is an effective option. The question of whether to fix a posterior compartment prolapse in the absence of defecatory symptoms at the time of other pelvic organ prolapse procedures, specifically when restoring the apical compartment, is a persistent and unanswered question in our field.

The objective of this secondary analysis was to describe the occurrence of posterior prolapse and obstructed defecatory symptoms in women a minimum of 5 years after abdominal sacrocolpopexy (ASC).

MATERIALS AND METHODS

This was an ancillary descriptive analysis of the Extended Colpopexy And urinary Reduction Efforts (ECARE) trial, conducted by the Pelvic Floor Disorders Network, aimed at assessing the progression of posterior compartment prolapse and symptoms of OD after ASC. Data from women enrolled in ECARE have been previously presented.(13) Included participants were those enrolled at ECARE sites that performed in-person follow up who had available baseline and 5-year subjective and objective outcome measures or who had reoperation in the posterior compartment over the 5 year interval. We separated this cohort of participants into 3 groups based on baseline posterior POP-Q point Ap and concomitant posterior repair (PR): No PR (Ap<0); No PR (Ap≥0); and +PR. Decision for PR was at surgeon’s discretion and included any posterior colporrhaphy, perineorrhaphy or sacrocolpoperineopexy as reported by surgeons at the time of index procedure.(14) The initial CARE protocol did not standardize the length or width of the posterior graft arm, the number of sutures used to anchor the mesh to the posterior vagina, or the technique for sacrocolpoperineopexy. Twenty-one out of 23 sacrocolpoperineopexies were performed by a single surgeon.

Three outcome definitions of failure were examined at five years following surgery. Anatomic failure was defined as a posterior prolapse (pPOP) of Ap≥ 0. Obstructed defecatory (OD) symptoms were defined as moderate or greater bother (≥ 2) on at least one of Pelvic Floor Distress Inventory questions 4, 7, or 8, which represent digital assistance to defecate, excessive straining, or a feeling of incomplete evacuation.(15) Because pPOP and OD symptoms were only assessed at the 5-year time point, we also aimed to capture additional failures that may have occurred prior to the 5-year endpoint. Thus, a composite failure outcome was examined, defined as both pPOP and OD symptoms or reoperation in the posterior compartment over the 5-year interval. This assumed that if participants had interval surgery then they had a symptomatic pPOP, and those participants were considered “failures” regardless of presence of 5-year symptom or objective data.

If the participant did not have anatomic or symptom outcomes available at the time point before her retreatment, we considered the symptom and prolapse failure outcomes to be missing. However, because she could have failed based on either of these criteria any time after her last visit and before the retreatment, she was considered a failure for the composite outcome. For those with available information on subjective or objective data prior to the retreatment, the data were reported for the respective outcomes. Because the CARE study did not collect data about why a PR was or was not performed, this analysis was considered exploratory, and summary results are presented descriptively without any statistical comparisons between the groups. Specifically, outcome sample proportions and confidence intervals using the exact (Clopper-Pearson) method are presented.

RESULTS

Baseline characteristics were not different between those individuals enrolled in ECARE versus the original CARE cohort. (13) Outcome and reoperation data were available for 60% (90/149) of women enrolled at ECARE sites that conducted in-person follow up. Mean follow-up of this cohort was 7.1 years +/− 1.0 year. There were 37 participants in the No PR (Ap<0); 24 participants in the No PR (Ap≥0); and 29 participants in the +PR group. The majority of the PR procedures were sacrocolpoperineopexy with perineorrhaphy (n=22 or 76%), 6 (21%) participants had perineorrhaphy alone and only 1 had sacrocolpoperineopexy only. Baseline characteristics of each group are shown in Table 1. Overall, the mean age was 62 years (SD±8), and participants were predominantly white (92%), married (72%), highly educated and parous with a median (range) of parity of 3 (1-10). Forty-three percent had prior prolapse surgery and 81% had a prior hysterectomy.

Table 1.

Baseline Characteristics of women undergoing ASC¹

	No PR (Ap<0) (n=37)	No PR (Ap≥0) (n=24)	+PR (n=29)
Age (y) – Mean (SD)	61.3 (7.0)	63.5 (8.3)	60.6 (9.8)
BMI (kg/m2) – Mean (SD)	26.5 (5.4)	25.8 (3.3)	26.4 (4.1)
Parity – Median (Range)	3 (1-7)	2.5 (1-10)	2 (1-6)
Race – no./total no. (%)
White	33/37 (89.2%)	24/24 (100.0%)	26/29 (89.7%)
Black	2/37 (5.4%)	0/24 (0.0%)	3/29 (10.3%)
Other	2/37 (5.4%)	0/24 (0.0%)	0/29 (0.0%)
Education – no./total no. (%)
Less than high school	1/37 (2.7%)	3/24 (12.5%)	3/29 (10.3%)
Completed high school or equivalent	11/37 (29.7%)	10/24 (41.7%)	12/29 (41.4%)
Some college or higher	25/37 (67.6%)	11/24 (45.8%)	14/29 (48.3%)
Smoking – no./total no. (%)	3/37 (8.1%)	1/24 (4.2%)	1/29 (3.4%)
Prior hysterectomy – no./total no. (%)	29/37 (78.4%)	21/24 (87.5%)	23/29 (79.3%)
Prior prolapse surgery – no./total no. (%)	17/37 (45.9%)	15/24 (62.5%)	7/29 (24.1%)
Randomized to Burch procedure – no./total no. (%)	14/37 (37.8%)	15/24 (62.5%)	9/29 (31.0%)
Culdeplasty – no./total no. (%)	13/37 (35.1%)	6/24 (25.0%)	22/29 (75.9%)
Paravaginal repair – no./total no. (%)	3/37 (8.1%)	1/24 (4.2%)	0/29 (0.0%)

¹The population for this analysis has also been subset to women in the E-CARE clinic follow-up population who have non-missing outcomes data at the baseline and 5-year time points (n=90).

ASC = Abdominal Sacrocolpopexy; BMI = Body Mass Index; PR = Posterior repair

Table 2 Summarizes the 5-year anatomy, symptoms and composite failure for each group. By definition, none of the participants in the No PR (Ap<0) group had distal posterior prolapse at baseline, but 9/37 (24%, 95% confidence interval (CI) (11.8%-41.2%)) had baseline OD symptoms. At 5 years, only 2/36 (6%, 95% CI (0.1%-18.7%)) developed de novo pPOP at or beyond the hymen and one of these had OD symptoms at 5 years, making her a “composite failure.” A total of 5/36 (14%, 95% CI (4.7%-29.5%)) in the No PR (Ap<0) group had OD symptoms without evidence of pPOP at or beyond the hymen at 5-year follow up (5 year information for ID1 is missing thus only 36 participants have anatomical outcomes in group 1).

Table 2.

Summary of 5-year outcomes in each group

Outcomes (%)	No PR (Ap<0) (n=37)			No PR (Ap≥0) (n=24)			+PR (n=29)
	Before	After	Change	Before	After	Change	Before	After	Change
Posterior compartment prolapse Ap≥ 0 *	0 / 36 (0%)	2 / 36 (5.6%)	2 / 36 (5.6%)	24 / 24 (100.0%)	1 / 24 (4.2%)	−23 / 24 (−95.8%)	11 / 26 (42.3%)	3 / 26 (11.5%)	−8 / 26 (−30.8%)
Obstructed defecatory symptoms **	9 / 37 (24.3%)	7 / 37 (18.9%)	−2 / 37 (−5.4%)	9 / 24 (37.5%)	4 / 24 (16.7%)	−5 / 24 (−20.8%)	13 / 27 (48.2%)	5 / 27 (18.5%)	−8 / 27 (−29.6%)
Posterior compartment prolapse with obstructed defecation or reoperation (composite failure)***	0 / 37 (0%)	2 / 37 (5.4%)	2 / 37 (5.4%)	9 / 24 (37.5%)	0 / 24 (0%)	−9 / 24 (−37.5%)	9 / 29 (31.0%)	4 / 29 (13.8%)	−5 / 29 (−17.2%)
Posterior compartment prolapse without obstructed defecation	0 / 36 (0%)	1 / 36 (2.8%)	1 / 36 (2.8%)	15 / 24 (62.5%)	1 / 24 (4.2%)	−14 / 24 (−58.3%)	3 / 26 (11.5%)	2 / 25 (8.0%)	−1 / 25 (−3.5%)
Obstructed defecatory symptoms but no posterior compartment prolapse	9 / 36 (25.0%)	5 / 36 (13.9%)	−4 / 36 (−11.1%)	0 / 24 (0%)	4 / 24 (16.7%)	4 / 24 (16.7%)	5 / 26 (19.2%)	3 / 25 (12.0%)	−2 / 25 (−7.2%)
No obstructed defecatory symptoms and no posterior compartment prolapse	27 / 36 (75.0%)	29 / 36 (80.6%)	2 / 36 (5.6%)	0 / 24 (0%)	19 / 24 (79.2%)	19 / 24 (79.2%)	10 / 26 (38.5%)	20 / 25 (80.0%)	10 / 25 (41.5%)

^*Participants in this table are those in the E-CARE clinic follow-up population who have non-missing outcomes data at the baseline and 5 years (N=90).

^**The discrepancy in denominators is due to the inclusion of 5 participants who met the definition of failure but did not have complete anatomic and subjective data at five years. One participant in group 1 did not have anatomic data at 5 years. Two participants in group 3 had missing symptoms data.

^***Participants who had interval repairs (N=5) were classified as composite failures but were only classified as failures for posterior compartment prolapse or obstructed defecatory symptoms if data were available to classify them as such prior to retreatment.

PR = Posterior repair

All of the participants in the No PR (Ap≥0) group had pPOP at baseline; 9/24 (37%, 95% CI (18.8%-59.4%)) had baseline OD symptoms. However, even without PR, nearly all of these participants [23/24 (96%, 95% CI (78.9%-99.9%)] demonstrated sustained resolution of the posterior prolapse from apical suspension alone and none underwent reoperation within 5 years. Roughly half of the participants with baseline OD symptoms had resolution of symptoms without PR and none in this group developed de novo OD symptoms or underwent reoperation for posterior compartment indications within 5 years.

Of those women in the +PR group only 9/29 (31%, 95% CI (15.3%-50.8%)) had pPOP (Ap≥ 0) with OD symptoms at baseline. Of the 11 women with pPOP at baseline, 3 (27%, 95% CI (6.0%-61.0%)) developed recurrent or had persistent pPOP at or beyond the hymen at 5 years, and 4 in the +PR group underwent repeat PR (ID 2,3,4,5 in Table 3). Overall, rates of OD symptoms improved in all 3 groups after ASC regardless of baseline pPOP or PR, although symptoms were not uncommon at 5 years with rates ranging from 17-19% across the groups (Table 2).

Table 3.

Outcome data on five participants who underwent repeat PR within 5 years

			Baseline		Post-surgery visit(s) prior to Time of repeat PR		5 years
ID	Baseline Group Assignment & PR type	Prior PR	Ap≥0	OD symptoms	Ap≥0	OD symptoms	Ap≥0	OD symptoms	Retreatment details:
ID1	No PR (Ap<0);	Yes	No	No	Missing	Yes	Missing	Yes	Underwent PR between 12-24 months follow up visits Obstructed defecatory symptoms were reported before retreatment. No anatomic data available.
ID2	+PR (Received perineorrhaphy and sacrocolpoperineopexy repairs)	No	Yes	Yes	No	No	Missing	Missing	Underwent PR between 6-12 months follow up visits. No posterior prolapse or obstructed defecatory symptoms reported before retreatment.
ID3	+PR (Received perineorrhaphy repair only)	No	No	No	No	No	Missing	Missing	Underwent PR between 12-24 months follow up visits. No posterior prolapse or obstructed defecatory symptoms reported before retreatment.
ID4	+PR (Received perineorrhaphy and sacrocolpoperineopexy repairs)	No	No	No	Missing	Yes	Missing	Yes	Underwent PR between 24 months – 3 year follow up visits. Obstructed defecatory symptoms were reported before retreatment. No anatomic data available.
ID5	+PR (Received perineorrhaphy repair only)	No	Yes	Yes	Yes	Yes	Yes	Yes	Underwent PR between 6-12 months follow up visits. Posterior prolapse detected and obstructed defecatory symptoms reported before retreatment.

OD = Obstructed Defecation; PR = Posterior repair

The five participants who had reoperation in the posterior compartment are described in Table 3. One participant (ID 1) had no baseline posterior compartment prolapse and did not have a concomitant PR, but developed OD symptoms and had reoperation between 12 and 24 months after index procedure. This individual had a prior PR and anatomic measures prior to reoperation were not available. The other 4 participants who had reoperation all had a concomitant PR at time of the index procedure, but no previous PR. Thus, all participants who required reoperation had a prior PR at some point. Of the 4 women with reoperation in the +PR group, 2 had pPOP at baseline and 2 did not. The reason for reoperation was not recorded for all participants. However, 3 participants (ID 1, 4 and 5), at minimum, had OD symptom failure prior to reoperation based on symptoms, and one (ID 5) also had anatomic failure recorded prior to the intervention.

CONCLUSION

This analysis of the ECARE data poses the question: “Is it necessary to perform a concomitant posterior vaginal wall prolapse surgery in women undergoing abdominal sacrocolpopexy?” Because those women with baseline posterior vaginal wall prolapse (Ap≥ 0) maintained good anatomic support (Ap<0) and reduced OD symptoms up to 5 years after ASC, despite lack of performing a concomitant posterior procedure, there may be a reason to study expectant management. Moreover, reoperation in the posterior compartment occurred most commonly in those women who did undergo a posterior procedure at the time of ASC. This paradox in outcomes suggests likely surgeon bias, however we were unable to capture the etiology of this bias. Thus, we feel there is a need to better define the indication for posterior prolapse surgery at the time of planned sacrocolpopexy.

Isolated posterior vaginal prolapse may occur in association with underlying bowel abnormalities, such as colonic transit disorders, redundant sigmoid or concomitant rectal prolapse. More commonly, posterior vaginal prolapse accompanies other forms of pelvic organ prolapse. Thus, when surgery is selected for pelvic organ prolapse, the indication for concomitant PR may be based on presence or absence of symptoms. Our data would suggest that this was not the case, as fewer than 50% of those undergoing PR had obstructed defecation symptoms. Therefore, one would expect that another indication for the posterior repair would be anatomic defects, however only 42% who received PR had prolapse at or beyond the hymen and 38% had neither anatomic prolapse nor symptoms. This highlights that the decision to proceed with PR is not evidence-based and may depend on the mechanism and/or efficacy of the apical suspension technique, other procedure-specific approaches, the residual presence of a gaping genital hiatus despite apical support or more likely, surgeon preference. This preference may impact not only the surgeon’s propensity to perform primary PR, but subsequent PR after the index surgery. As with most surgical recommendations, surgeon preference is likely to closely mimic the heritage and practices of their training. Specifically, a perineorrhaphy is intended to repair level 3 support (perineal body) and narrow the genital hiatus, and likely has an impact on level 2 support, if the perineal body is adequately reattached to the rectovaginal fascia. However, the impact of these procedures on posterior vaginal wall support has not been well studied and deserves further investigation. This analysis clearly indicates that variability exists in the decision to perform concomitant PR at the time of ASC. This variability is not explained by POPQ point Ap or symptoms alone, but could be driven by the presence of vaginal laxity or a widened introitus.

Given that there are risks associated with performing a posterior procedure such as dyspareunia, bleeding and potential mesh erosion with ASC, it may be better to judiciously perform a staged posterior procedure for the minority of patients who develop new or persistent posterior wall prolapse after ASC. As with all prolapse repairs, recurrences are to be expected over time.(14) Prospective trials assessing the risks and benefits of concomitant repair of the posterior compartment when undergoing ASC are warranted before definitive recommendations can be made regarding staged procedures. We hope that these data spur interest in the topic and provide sample size estimates for future trials.

These findings are notably different than our 1 year outcomes where Bradley et al. demonstrated that median posterior wall measurements were −3.0 cm and −2.0 cm between those with and without concurrent posterior procedures, respectively, and these measures were not significantly different between groups.(8) In our study, the incidence of symptomatic posterior prolapse and/or reoperation for posterior prolapse was greatest in those who had a concomitant posterior procedure. Although the anatomic failure and reoperation rates from our analysis are greater at 5 years in women who received a posterior procedure, women with moderate or severe baseline defecatory symptoms appear to maintain improvement up to 5 years after surgery. Collectively, these data suggest that in the setting of ASC, a conservative approach could be considered to limit surgical duration and morbidity from concomitant posterior procedures, although we do not have information on how these women may have differed at baseline.

Some have advocated that posterior wall defects are a result of traction or displacement defects and anatomic correction will be achieved with the apical support procedure.(9) Data one year after ASC without any concomitant anterior or posterior repairs revealed continued restoration of posterior vaginal topography.(10) Other investigators described significant improvement in pelvic organ prolapse quantification points Ap, Bp and total POPQ stage with or without a concomitant PR at the time of ASC. With concomitant repair, the improvement in point Ap persisted 34 months after surgery, but mean Bp and stage of the posterior compartment returned to preoperative values after 10 months regardless of whether a posterior colporrhaphy had been performed; pre- and post-operative defecatory and other posterior compartment symptoms were not reported.(16) Transabdominal rectocele correction with posterior extension of mesh placement has also been described. (17-19) In 29 women a mean of 14 months out from the procedure, a significant improvement in posterior compartment prolapse was noted, but symptom outcomes were mixed with increases in constipation and incomplete defecation, but a decrease in fecal soiling and dyspareunia.(19) At a mean time of 26 months post ASC with posterior mesh extension, post-operative rectoceles were noted in 55% and an increase in “high outlet constipation” was also described.(18) Our data too suggest that posterior extension of mesh with sacrocolpoperineopexy does not guarantee success.

The symptoms associated with posterior vaginal prolapse are poorly understood and may be non-specific. Multiple studies have revealed that defecatory symptoms may or may not increase with prolapse stage in women seeking care for advanced prolapse.(5, 20-23) Despite mixed associations, many providers infer that a cause-effect relationship exists with constipation causing posterior wall prolapse or vice versa. Reasons include biologic plausibility; such as an underlying structural defect that results in stool trapping into the posterior defect, that when corrected, resolves OD symptoms. (24) Several studies support this concept and demonstrate symptom improvement after surgery to correct posterior prolapse.(1, 5, 7, 8) However, not all women with OD symptoms and prolapse improve after surgical correction. This is likely due to the fact that there are other risk factors such as vaginal childbirth, advancing age, and increasing body mass index, concomitant medical conditions and medications that may prevent some women from achieving resolution of OD symptoms after prolapse surgery. Given that symptoms of obstructed defecation (digital assistance to defecate, excessive straining, or a feeling of incomplete evacuation) may be bothersome to any type of vaginal prolapse, not just in the posterior wall, it is possible that existing symptom-based questionnaires are unable to distinguish between symptoms of advanced prolapse and defecatory dysfunction. It is easy to see how symptoms such as stool trapping, often with a need to manually assist with defecation, “constipation” and a sense of protrusion, may reported by patients with vaginal prolapse.

This analysis has several strengths and limitations. The strengths include long term outcomes on a cohort of women using standardized outcome measures across multiple sites. Limitations include the fact that we were unable to account for selection bias in the surgeon’s decision to perform any posterior procedure at all and, when chosen, the type of posterior procedure (posterior colporrhaphy, perineorrhaphy, and sacrocolpoperineopexy). Additionally, the techniques for the various types of PR were not standardized across sites or surgeons. Therefore, it is not possible to associate any of the posterior procedures to a specific type of repair. We postulate that some surgeons, during the preoperative evaluation, support the vaginal cuff or cervix with the posterior blade of the speculum, or a large procto-swab, and have the participant strain to assess posterior wall support attempting to simulate the result after the ASC. Other surgeons assess the posterior vaginal wall intraoperatively immediately after the apical suspension to assess for residual posterior vaginal prolapse and use that assessment to decide whether or not to perform a PR. Additionally, some surgeons may perform a concomitant perineorrhaphy in participants with an enlarged genital hiatus (POPQ point GH) so that should recurrent symptomatic prolapse recur, a pessary would be more easily fitted. Data demonstrating the clinical utility of either of these approaches are lacking, but could be included in future studies. Future studies that immediately assess posterior wall position in the operating room after ASC may help identify a subgroup of women, if any, who may benefit from concomitant posterior procedures. As expected with any long-term study on quality of life conditions, sample size tends to decrease over time. This analysis was performed on only 28% of the original CARE population; however, many of the subjects excluded were considered “administrative” dropouts due to changes in site participation which should not be a source of bias. We did capture 60% of women who continued in ECARE at sites that performed in-person follow up. This analysis was limited to relatively small sizes in the three comparative groups which prevented statistical analyses, and it is likely that differences exist between the three groups, which we are unable to distinguish.

For patients undergoing ASC for apical prolapse, there seems to be a possibility of achieving normal posterior wall support (Ap<0) and resolution of OD symptoms up to 5 years after surgery regardless of their baseline findings or whether surgeons choose to perform concomitant posterior procedure. Overall OD symptoms may improve after ASC regardless of baseline posterior wall support or intervention. However, these data highlight the need to prospectively study the role of PR at the time of apical surgery. Given the non-specific symptoms that are attributed to posterior prolapse, further studies are needed to clarify the evaluation for constipation and/or defecation abnormalities in the setting of the pre-surgical evaluation for pelvic organ prolapse. Additionally, as with all prolapse repairs, recurrences are to be expected over time.(14) The indications for concomitant as well as subsequent PR (as an isolated procedure) following ASC will also benefit from additional study.